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DURATION: 4-6 weeks based on Physical Therapy evaluation findings. Estimated length of treatment
to discharge is 6-12 weeks. Continued formal treatment beyond meeting Self-
Management Criteria will be allowed when:
1) Patient out of work or to hasten return to work full duty.
2) Athlete needs to return to organized athletic program.
Initiate a formal course of rehabilitation 2-3 times per week until SELF-MANAGEMENT
CRITERIA has been met. Frequency of weekly appointments will depend on patient's
availability, working status, and choice/interest. When patient meets the following SELF-
MANAGEMENT CRITERIA (estimated at 3-6 weeks):
Symmetrical hip and ankle active range of motion.
Knee active range of motion 0-130.
Good voluntary contraction of quadriceps complex particularly that of the vastus medialis
oblique.
Minimal to no limitations in patellar mobility.
Normal gait pattern.
4+/5 quadriceps and hamstring strength.
Trace to 1+ effusion.
then patient can be instructed in either home exercise program or program to be performed at a
local health club with follow-up appointments every month until discharge criteria has been met.
7 Marsh Brook Drive, Suite 101, Somersworth, NH 03878 Tel:(603) 749-6686 Fax:(603) 749-9270
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DISCHARGE CRITERIA
No evidence of knee instability.
Knee active/passive range of motion symmetrical to uninvolved knee.
Patellar mobility symmetrical to uninvolved knee.
No effusion.
5/5 strength of hip and ankle musculature.
Return to work full duty.
Met, or consistently progressing toward, established functional/objective outcomes.
Failure to progress.
Failure to comply.
Often times, return to sports activity is a goal after MCL injury. The patient can return to sports when the
following criteria has been met:
Full range of motion.
No swelling.
No evidence of instability.
Complete walk/jog program, one legged hop for distance test, and timed hop test is 90% as
compared to uninvolved knee.
Use of functional knee brace with medial stabilizer if deemed necessary by physical
therapist/physician.
--TREATMENT GUIDELINES--
GRADE I INJURY
WEEK 1 TO 2
GOAL: Meet SELF-MANAGEMENT CRITERIA.
LAND COMPONENT:
Modalities as indicated to control pain/inflammation.
FES for muscle re-education of the quadriceps complex emphasizing the vastus medialis oblique
if inhibition noted for multi-angle isometrics at 90, 60, and 30.
Manual patellar mobilization emphasizing medial glide and tilt.
Patient performing home exercise program for isotonic/Theraband strengthening program to
include abdominals, back extensors, squats, calf raises, multi-hip, hamstring curls, and ankle
Theraband.
Perform balance/proprioception activities.
WATER COMPONENT:
Shallow Water: (May add hydrofit cuffs at this phase to increase resistance)
Walking forward/backward/sideways, clapping under, clapping behind, four-count walking kicks
forward/backward, lunges forward/backward, straight leg walking forward/backward, squats, toe
raises, step-ups forward and lateral.
PREs Hip/Knee/Ankle exercises open chain all planes.
Balance/Proprioception Kickboard push/pull with added diagonals two-legged progressing to
one-legged, one-legged balance with eyes open/eyes closed, tubing exercises in upper
extremities two-legged progressing to one-legged multi-directional.
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GRADE I INJURY
WEEK 1 TO 2 (continued)
WATER COMPONENT:
Deep Water:
Open Chain Exercises:
Splits/Spreads, single/double knee to chest, corkscrews, bicycling, running supine prone,
sidelying running forward/backward, deep water running with/without tethers.
WEEKS 3 TO DISCHARGE
GOAL: Meet Discharge Criteria.
LAND COMPONENT:
Continue with treatment as indicated in Week 1 to 2.
Progress weights and strengthening program as indicated.
Perform one-legged hop test for distance and for time.
WATER COMPONENT:
(Shallow and Deep Water):
Continue with treatment as indicated by Week 1 to 2. Emphasis on increased resistance using
either fins, cuffs, or tethers.
Add sports specific exercises and plyometrics.
GRADE II INJURY
WEEK ONE
GOALS:
1. Active range of motion -10 to 70.
2. Independent weight bearing as tolerated gait pattern with use of crutches and brace on if
appropriate.
3. Independent with home exercise program and edema reduction techniques.
BRACE: Hinged long leg brace bent into varus. Range of motion limit -10 of extension. Brace per
physician discretion.
WATER COMPONENT:
Shallow Water:
Walking forward/backward/sideways emphasizing equal weight bearing and ambulating without
flexed knee. (May use underwater FES/EMG for quadriceps complex emphasizing vastus
medialis oblique if inhibition noted.)
Perform clap under, clap behind, partial squats, toe raises, modified lunges, straight leg walk, all
exercises forward/backward.
Open chain PREs for hip/knee/ankle avoiding valgus stress on knee. Perform gastrocsoleus
stretch.
Deep Water:
Splits/Spreads (emphasis on abduction vs. adduction), corkscrews, single knee to chest, double
knee to chest, and bicycling.
WEEK TWO
GOALS:
1. Active range of motion 0-100.
2. Good recruitment of vastus medialis oblique.
3. 1+ effusion.
BRACE: Continue with hinged long leg brace with range of motion limit -10 of extension as per
physician discretion.
CRUTCHES: Can wean off crutches with brace on/off as per physician discretion.
LAND COMPONENT:
Modalities as indicated to decrease pain/inflammation.
Patellar mobilization emphasizing superior glide and medial glide and tilt.
Continue with home exercise program as in Day 1 to 7.
WATER COMPONENT:
Shallow Water: (May add hydrofit cuffs at this phase to increase resistance)
Continue as in Week 1 adding four-count walking kicks forward/backward.
Initiate balance/proprioception activities with eyes open/eyes closed using kickboard and tubing
with eyes open and progressing to eyes closed.
Deep Water:
Continue as in Week 1 adding supine prone exercises, standing on kickboard or barbell with
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upper extremity propulsion forward/backward. Add squats on kickboard/barbell.
WEEK THREE
GOALS:
1. Active range of motion 0-125.
2. No effusion.
3. Normal gait pattern with brace on.
BRACE: Continue with hinged long leg brace with range of motion limit -10 of extension if appropriate.
LAND COMPONENT:
Continue with treatment as indicated in Week Two.
Continue with manual stretching, patellar mobilization, and functional electrical stimulation as
indicated.
Home exercise program to be performed for comprehensive isotonic/Theraband strengthening
program to include abdominals, back extensors, partial squats, calf raises, hamstring curls, and
multi-hip machine. Brace to be worn while performing multi-hip exercises. Theraband for
ankle/foot musculature.
WATER COMPONENT:
Shallow Water:
Continue with treatment as indicated in Weeks 1 to 2 adding increased resistance/ turbulence.
Deep Water:
Continue with treatment as indicated in Weeks 1 to 2 adding 180/360 squats on barbell/
kickboard, running in deep end with/without tethers, teeters on barbell with added 180/360, and
perform sidelying running forward/backward.
WEEKS 4 TO 5
GOALS:
1. Meet SELF-MANAGEMENT CRITERIA.
2. Progress to land by week six.
BRACE: Can discontinue brace if no medial laxity or pain with valgus stress testing as determined by
physician.
LAND COMPONENT:
Continue with manual stretching and patellar mobilization as indicated.
Continue with comprehensive home strengthening program.
Progress balance/proprioception activities.
Continue to progress aerobic conditioning on land using the following: Stairmaster, cross country
ski device, stationary bicycle, walking.
WATER COMPONENT:
(Shallow and/or Deep Water):
Continue as previously outlined water treatment. Can begin sports specific exercises,
plyometrics, or work simulated activities. May continue to add increased resistance with cuffs,
fins, or tethers.
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WEEKS 6 TO DISCHARGE
GOAL:
1. Meet DISCHARGE CRITERIA.
2. Completely transitioned to land at this phase.
For advanced exercises, please refer to Advanced Lower Extremity Aquatic Exercise Protocols.
RM/aoc
12/00, Rev. 1/04, 2009